Importance Few primary care patients complete guideline-recommended out-of-office blood pressure (BP) monitoring prior to having hypertension diagnosed. Objective To evaluate the effectiveness of a behavioral theory–informed, multifaceted implementation strategy on out-of-office BP monitoring (ambulatory BP monitoring [ABPM] or home BP monitoring [HBPM]) among patients with new hypertension. Design, Setting, and Participants This 2-group, pre-post cluster randomized trial was conducted within a primary care network of 8 practices (4 intervention practices with 99 clinicians; 4 control practices with 55 clinicians) and 1186 patients (857 intervention; 329 control) with at least 1 visit with elevated office BP and no prior hypertension diagnosis between October 2016 and September 2017 (preimplementation period) or between April 2018 and March 2019 (postimplementation period). Data were analyzed from February to July 2023. Interventions Usual care (control group) or a multifaceted implementation strategy consisting of an accessible ABPM service; electronic health record (EHR) tools to facilitate test ordering; clinician education, reminders, and feedback relevant to out-of-office BP monitoring; nurse training on HBPM; and patient information handouts. Main Outcomes and Measures The primary outcome was patient completion of out-of-office BP monitoring within 6 months of an eligible visit. Secondary outcomes included clinician ordering of out-of-office BP monitoring. Blinded assessors extracted outcomes from the EHR. Results A total of 1186 patients (857 intervention; 329 control) were included, with a mean (SD) age of 54 (16) years; 808 (68%) were female, and 549 (48%) were Spanish speaking; among those with race and ethnicity documented, 123 (10%) were Black or African American, and 368 (31%) were Hispanic. Among intervention practices, the percentage of visits resulting in completed out-of-office BP monitoring increased from 0.6% (0% ABPM; 0.6% HBPM) to 5.7% (3.7% ABPM; 2.0% HBPM) between the preimplementation and postimplementation periods ( P = .009). Among control practices, the percentage of visits resulting in completed out-of-office BP monitoring changed from 5.4% (0% ABPM; 5.4% HBPM) to 4.3% (0% ABPM; 4.3% HBPM) during the corresponding period ( P = .94). The ratio of relative risks (RRs) of out-of-office BP monitoring in the postimplementation vs preimplementation periods for intervention vs control practices was 10.5 (95% CI, 1.9-58.0; P = .01). The ratio of RRs of out-of-office BP monitoring being ordered was 2.2 (95% CI, 0.8-6.3; P = .12). Conclusions and Relevance This study found that a theory-informed implementation strategy that included access to ABPM modestly increased out-of-office BP monitoring among patients with elevated office BP but no hypertension diagnosis. Trial Registration ClinicalTrials.gov Identifier: NCT03480217
Background: The frequency and clinical significance of non-sustained ventricular tachycardia (NSVT) detected on ambulatory monitors in pediatric and congenital heart disease (CHD) patients has not been thoroughly investigated. We sought to examine the prevalence of NSVT, analyze the presence of associated cardiovascular disease, and describe changes in management. Methods: We performed a retrospective cohort study of all patients evaluated in cardiology clinic at Cleveland Clinic who were found to have NSVT on ambulatory Zio monitors (2017 and 2023). Kaplan Meier curves and Cox proportional hazards model were performed to analyze time to NSVT detection and factors associated with detection. Results: Among 2805 patients, 172 (mean age 29 ± 14, 51% male) had NSVT yielding a prevalence of 6% and a mean monitoring duration of 7.5 ± 5.5 days. Cardiac diagnoses were as follows: 98 (57 %) CHD, 44 (26%) structurally normal hearts, 14 (8%) cardiomyopathy, 10 (6%) connective tissue disorder, and 6 (3%) channelopathy. Monitoring indications included symptoms (97, 56%), history of arrhythmias (34, 20%), screening (36, 21%) and others (5, 3%). Mean day of NSVT detection was 4.3 ± 3.7 years without significant difference amongst the various underlying cardiac diagnoses (p = 0.2). Of the patients who had a repeat ambulatory monitor, 39/113 (34%) were found to have NSVT. Management changes were made in 56 (32%) patients: medication change in 46, EP study in 1, implantable loop recorder placement in 4, and ICD placement in 5. Five patients died during the study period with only 1 suspected sudden cardiac death. The likelihood of NSVT detection increased with longer monitoring duration with only 55% of cases detected at 2 days (Figure 1). In a multivariable model, monitoring duration (HR 0.8, 95% CI: 0.77-0.84, p < 0.001) but not underlying diagnosis, age, monitor indication, or single ventricle status, was associated with likelihood of NSVT detection. Conclusions: NSVT is not an uncommon arrhythmia in pediatric and CHD patients with increasing prevalence with longer monitoring duration regardless of underlying cardiac etiology. Although medical management changes based on monitor findings were frequent, sudden death was rare.
The most common form of preexcitation in the pediatric population is due to Wolff-Parkinson-White syndrome (WPW) where atrioventricular (AV) conduction occurs partially or entirely through a congenital accessory AV bypass tract.1 Acquired WPW has been described when AV accessory pathways develop across suture lines after surgery for congenital heart disease (CHD).2–3 Fasciculoventricular (FV) pathways that manifest after CHD surgery have not been described previously. Although FV pathways do not participate in arrhythmias, their effects manifest as de novo preexcitation on surface electrocardiograms (ECGs).
